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Full text of "Navy Department BUMED News Letter Vol. 5, No. 3, February 2, 1945"

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NavMed 369 RESTRICTED 




Editor. - Comdr. F. R. Bailey, (mc) u. s. n. r. 



Vol. 5 Friday, February 2, 1945 No. 3 



TABLE OF CONTENTS 

Plague: Epidemiology 1 Neurocirculatory Asthenia 16 

Plague: Prophylaxis and Therapy 6 New Plastic Arm Splint 17 

Streptomycin and Str eptothricin 7 Fracture Immobilisation : Combat. ..17 

Gramicidin S 9 Surgery of Heart Wounds 18 

Salicylate: Physiologic Effects 9 Pericardial Tamponade: Therapy.... 20 

Penicillin in Aqueous Humor 13 Shigellosis, Sulfonamides in 22 

Anterior Chamber Infections 14 Falciparum Malaria: Therapy 23 

Penicillin in Empyema 15 Sodium Arsenite Toxicity. 24 

Epidemic Hepatitis: Transmission... 16 Too Much Rest 25 

CMR Bulletin * ..27 



Form Letters: 

Human Plasma and Serum Albumin.... SecNav 28 

Hospital Established at Corvallis, Oregon... SecNav 28 

Change in Navy Regulations (NNC) — OpNav 29 

Petrolatum Removed from Life Rafts BuMed 29 

Handling of Amalgam, Precious -Metal Scrap BuMed ...30 

Conservation and Transfer of X-Ray Films BuMed 31 

Abstract of Patients, Discontinuance of BuMed 31 

Physical Examination Prior to Discharge , BuMed 32 



plague: Epidemiology: Plague is primarily a disease of a large number 
of species of wild and domestic rodents. In rodents the disease maybe either 
acute or chronic, either epizootic or enzootic. When it occurs in wild rodents, 



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it is usually known as- sylvatic plague . Plague i n humans i s usually con- 
tracted through the bites of infected fleas, although infection may occur in 
other ways. The causative bacterium is Pasteurella pestis , a gram-negative, 
pleomorphic, bipolar bacillus. Three clinically and epidemiologically dis- 
tinct types of human plague occur: bubonic, pneumonic and septicemic. 

Geographic distribution: It is difficult to describe accurately the geo- 
graphic distribution of plague. A careful examination of rodent. population 
throughout the world would be required to ascertain reliably the distribution 
ofplague. The geographic distribution of plague is continually changing and is 
intimately associated not only with the dispersal ofplague through rodent popu- 
lations but also with the migrations of the rodents themselves . Because the com- 
mon commensal rats often are infected, plague can be spread in addition 
by the transportation of these rats in trains, airplanes and ships. Since the 
pandemic of 1894-1900 epidemic plague has decreased considerably in inci- 
dence. At the present time the heavy foci of human plague exist in Manchuria, 
parts of China, Indo-China, Java, Burma, India, British East Africa, Morocco 
and Madagascar. Small epidemics and sporadic cases have been reported in 
U.S.S.R., Spain, France, Senegal, Nigeria, New Caledonia, Belgian Congo, 
Angola, Algeria, Tunisia, Egypt, Union of South Africa, Ecuador, Peru, Bolivia, 
Chile, Argentina, Brazil, Iraq, Lebanon, Thailand, and Hawaii. Foci of syl- 
vatic plague are known to exist in western United States, Hawaii, Manchuria, 
Mongolia, China, Lake Baikal region of U.S.S.R., South Africa, British East 
Africa, Morocco, Madagascar, Venezuela, Colombia, Peru, Bolivia, Argentine, 
Paraguay, Brazil and the Guianas. 

Vectors: Xenopsy ila cheopis (Rothschild), the Oriental rat flea, is the 
most important rodent-to-man plague vector. This species has a wide dis- 
tribution in eastern Asia and as far north as the Amur River country, in Japan 
Formosa, Philippine Islands, Malay Archipelago, Malaya, Burma, India , 
Ceylon, Australia, numerous areas in Africa (including Madagascar), south- 
ern Europe and the Near East, the United States except the area between the 
Mississippi River and the Rocky Mountains and in numerous areas in South 
America and the West Indies. It is primarily a parasite of rats and mice. 
Xenopsyila astia (Rothschild), which occurs on rats and mice in India, Burma, 
Ceylon, Mesopotamia and Java, is a rather inefficient and occasional rat-to- 
man vector. Other rodent-to-man vectors are X e nopsyila brasiliense (Baker) 
(India and Africa) , Xenopsyila nubicus (Rothschild) which replaces cheopis in 
Africa, possibly Ctenocephalides canis (Curtis) (cosmopolitan) , and 
Nosopsvllus fasciatus (Bosc) (originally European - now cosmopolitan in and 
near harbor cities) . pulex irritans L. may serve as a man-to-man vector 
when it becomes infected from biting human septicemic cases. The above- 
mentioned fleas, with the exception of Pulex irritans . are important also as 
rodent-to-rodent vectors. Among others known to serve as rodent-to-rodent 
vectors are Xenopsyila eridos (Rothschild) (southern Africa) Ctenopsyllus 



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segnis (Schoenherr) (cosmopolitan on house mice) , Xenopsvlla hirsuta 
(Rothschild) (southern Africa), and Dinopsvllus lypusus (Jordan and 
Rothschild) (Africa). Many other species of fleas in various parts of the 
world are doubtlessly involved in rodent-to- rodent transmission of plague. 

There are several important points concerning the infection of fleas 
with plague which should be emphasized. In the first place a relatively 
small percentage of those which feed on infected animals actually become 
infected. Furthermore, infected fleas do not become infective unless the 
esophagus is blocked by a bacterial mass. Such fleas are unable to suck 
blood, and after becoming hungry become restless and bite voraciously. 
These are the individuals that transmit plague. ' 'Blocked" fleas rarely 
.survive more than 48 hours after the development of the block. Although 
both sexes may transmit the disease, females are more efficient than males. 
Plague infection usually causes fleas to die. In the case of Xenopsvlla cheopis 
death occurs within a month after infection; Nosopsvllus fasciatus may sur- 
vive for from two to four months. Feces of infected fleas contain plague 
bacilli which, when deposited on the skin, may gain entrance to the body 
through scratches. 

Fleas have only general host specificity. Xenopsvlla cheopis , for in- 
stance, is primarily a rodent flea, although it also attacks man and predatory 
mammals. In plague epizootics, when large numbers of domestic rats die, these 
fleas attack man readily. This is an important point in the epidemiology of ' 
plague . 

Reservoir hosts: Many species of rodents are known to be 
susceptible to plague; it seems possible that all rodents can be infected. 
Among the domestic species known to serve as reservoirs and immediate 
sources of infected fleas in epidemics of bubonic plague are the domestic 
species such as Rattus norvegicus (Berkenhout) , the Norway rat; Rattus 
rattus rattus (L.), the black rat; Rattus rattus alexandrinus (E. Geoffroy), 
the roof rat; Rattus rattus diardii (Jentink) , the Malayan house rat; and possi- 
bly Rattus rattus rufescens (Gray) , the common Indian rat. The first three 
are world-wide in their distribution and are associated with trade and com- 
merce, whereas, rufescens and diardii are Oriental in their distribution. All 
are readily transported from area to area by man. Rattus rattus frugivorus 
(Rafinesque) should also be included in this group. These species are fre- 
quently affected by epizootics of plague and under such circumstances are 
the immediate sources of infected fleas in bubonic epidemics. 

Certain other species, although not domestic in habit, are frequently in 
contact with native populations and are of importance. In Java, for instance, 
Rattus rattus argentiventer (Robinson and Kloss), Rattus rattus roq uei Sody, 



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Rattus concolor ephippium (Jentink) and Rattus concolor otteni Kopstein have 
such habits. 

The true sylvatic reservoirs are usually rodents of the families Sciuridae 
(squirrels, ground squirrels, susliks, etc.) and Gerbillinae (gerbils). This 
has been found to be true in enzootic areas of sylvatic plague in Mongolia, 
Manchuria, Astrakhan, South Africa and (?) South America. They constitute 
a vast uncontrollable reservoir from which domestic rats may become in - 
fected and from which sporadic human bubonic cases are derived. In Java 
wild species of rats serve as reservoirs. Rodents of the families Muridae 
(rats and mice), Jaculidae (jumping rats) and Leporidae (rabbits and hares) 
.are complementary plague hosts. Certain rodents which are primarily wild 
species are probably important in plague transmission because of the fact 
that they occasionally enter dwellings and in so doing spread the infection to 
the domestic species. Examples are Microtus arvalis . which in Astrakhan 
enters human dwellings in the fall and in which plague occurs epizootically, 
and Rattus coucha which in South Africa is affected epizootically and which 
may come in contact with the domestic rats. 

Epidemiology and control: The epidemiology of plague is extremely com- 
plex. The plague potentiality of an area is affected by the proximity of 
'sylvatic reservoirs and the habits of the species involved, the species and 
population densities of the domestic rats present, the flea fauna of the reser- 
voirs and domestic rats, the relation of the human population to the rat popu- 
lation, climate, importation of rats from other areas, housing, density of 
human population and numerous other factors. With the exception of ep i - 
demies in certain native populations, large plague epidemics almost invari- 
ably arise as the result of epizootics in populations of domestic rats. When 
the rate of infected domestic rats rises to five per cent or more, there is 
cause for alarm and immediate control measures are indicated. When these 
rats die, their fleas, particularly Xenoosvlla cheopis , attack humans, result- 
ing in the development of bubonic cases. Bubonic cases may become pneu- 
monic secondarily and from these, especially in temperate areas, primary 
pneumonic cases develop. These relationships of human and rodent plague 
are outlined in the Table. Although bubonic or pneumonic cases may become 
septicemic, it is probably only rarely that fleas become infected by attacking 
man. Among crowded natives in temperate regions epidemics of pneumonic 
plague develop from a few secondary pneumonic cases which were originally 
sporadic bubonic cases derived from sylvatic reservoirs. 

The primary principles in plague prevention are preventing immigration 
of rats into the area involved and controlling the rat population within it, 
since these species constitute the immediate source of infected fleas. When 
rat control is practiced during plague epidemics, special precaution must be 
taken against attacks by fleas from dead rats. In addition, prophylactic im- 
munization should be carried out. 



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RODENT PLAGUE 




SYLVATIC PLAGUE 
ENZOOTIC OR EPI- 
ZOOTIC IN WILD 
RODENTS. 



ENZOOTIC OR EPIZOOTIC 
PLAGUE IN DOMESTIC RATS 
OR WILD SPECIES WHICH 
ENTER NATIVE VILLAGES 




Flea transmission 
(skin) 



Flea transmission 
(mucous membrane) 




PRIMARY 
SEPTICEMIC i 
CASES. I 
I 



EPIDEMIC 
BUBONIC 
PLAGUE. 




SPORADIC 
BUBONIC 
CASES. 



Flea transmission 




BUBONIC 
CASES. 



PRIMARY PNEUMONIC 
PLAGUE FREQUENTLY 
EPIDEMIC IN TEMPER- 
ATE REGIONS. 



EPIDEMIC PNEUMONIC 
PLAGUE. ESPECIALLY 
IN NATIVE VILLAGES 
IN TEMPERATE CLIMATES 



HUMAN PLAGUE 



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The above measures are those directed against plague epidemics. Prevention 
of sporadic cases derived from sylvatic plague is difficult unless enzootic 
areas can be avoided. Control of the wild-rodent plague reservoirs is im- 
practicable. In both epidemic and sporadic cases of plague strict isolation 
should be enforced, and one should bear in mind the fact that the plague ba- 
cillus may persist in the convalescent patients as long as three weeks after 
all symptoms have disappeared. (Prev. Med. Div., BuMed - D. S. Farner) 

Plague: Preventive Medicine and Therapy : A formalin-killed plague 
vaccine is available on the Supply Table (Sl-180). This vaccine has not been 
tested in large series of cases with respect to the incidence of plague in vac- 
cinated individuals and unvaccinated controls. However, its experimental in- 
jection into animals is followed by the development of a considerable degree 
of immunity. In some instances its use in man has been followed by moder- 
ately severe local and general reactions. Recently collected reports on ap- 
proximately 5,500 antiplague vaccinations in the Armed Forces and in 7,500 
civilians indicate that this vaccine may produce local as well as general re- 
actions in a small, though variable, percentage of persons inoculated. The local 
reactions occasionally lead to abscess formation (Meyer OEMcmr-259). Ac- 
cording to a report recently received by the Bureau, out of one group of 9,781 
naval personnel vaccinated, five had reactions severe enough to necessitate 
rest in bed for 24 hours (Gezon) . 

The vaccine should be administered to naval personnel prior to their 
entry into areas where plague is endemic as well as to personnel upon the 
occasion of an outbreak of plague in the vicinity of the place in which they 
are stationed. 

Vaccines consisting of suspensions of living avirulent plague bacilli 
have been used frequently, especially in North Africa, Madagascar and Java. 
Because of the possibility of their transmitting the disease through being in- 
adequately attenuated, their employment in naval personnel is not recommended. 

The treatment of plague with sulfonamides was discussed in the Burned 
News Letter of March 3, 1944. Reports of the effectiveness of these drugs 
vary in different series because of differences in the technic of administration 
as well as because of the great difference in the threat to life presented o n 
the one hand by bubonic plague and on the other by the pneumonic and septi- 
cemic forms of the disease. 

There appears to be little room for doubt that sulfonamides are effective 
in the therapy of plague, especially the bubonic f orm . All workers empha- 
size the fact that sulfonamides to be effective must be given early in the course 



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of the disease and for at least twelve days after the return of the temperature 
to normal. Treatment should begin with heavy dosage. Sulfadiazine i s the 
drug of choice. It is considerably more effective than sulfathiazole in the 
therapy of experimental Pa steurella pestis infections in animals. 

A recent report to the Bureau concerning a small epidemic of bubonic 
plague occurring in a native population reveals some interesting facts with 
respect to treatment. There were 19 cases in the series. Five victims 
were found dead or were admitted to tjhe hospital in a moribund condition 
and died a few hours after admission. Two patients were treated only with 
80 c.c. of antiplague serum over a period of two days. Both seemed to be 
making dramatic recoveries, but after being allowed up on the fourth day, 
they suddenly died. Death was said to have been due to myocarditis. The 
other ten patients, who were seen early in the course of the disease, re- 
ceived treatment with sulfadiazine in heavy dosage at the onset followed by 
a lower dosage for a considerable period of time . Seven of these ten patients re - 
ceived, in addition, 50 c.c. of antiplague serum. All ten recovered CGezon). 

Plague, especially in its pneumonic form, is highly communicable, and 
medical department personnel caring for patients with this disease should be 
afforded the benefit of all available means of protection. The strictest isola- 
tion technic should be maintained. Protective vaccination must be carried 
out. It is recommended that prophylactic doses of sulfadiazine (at least 2.0 
Gm. a day) be given. 

Sheep antiplague sera have been widely used in the. treatment of plague. 
Their effectiveness has not been demonstrated. Efforts to obtain a potent 
serum through immunization of horses have not been successful. At present 
no antiplague serum of proved value is available in this country. Meyer has 
recently developed a rabbit serum which offers promise. The best thera- 
peutic results in experimental P. pestis infections in guinea pigs were ob- 
tained when both rabbit serum and sulfadiazine were used. 

Penicillin has no bacteriostatic activity against £. pestis in vitro, and 
it has failed therapeutically in laboratory infections. It is therefore not anti- 
cipated that penicillin will be effective in the treatment of plague. 

Streptomycin and streptothricin (mentioned elsewhere in this issue) have 
been found to possess bacteriostatic action in vitro in high dilution against 
plague bacilli and have proved effective (Meyer) in the treatment of experi- 
mental plague in animals. (Prev. Med. Div., BuMed - J. K. Curtis; Prof. 
Div., BuMed - F. A. Butler) 

jft 3f£ 3|C 3fc 



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Streptomycin and Streptothricin: New Antibiotics : The search for a 
chemotherapeutic agent effective against infections due to gram -negative 
organisms recently led to the isolation by Waksman and Woodruff (1) of 
streptothricin, derived from Actinomyces lavendulae . More recently a 
second antibiotic substance, streptomycin, has been isolated by S c hat z , • 
Bugle and Waksman (2) in crude form from a microorganism called 
Actinomyces griseus . 

According to Waksman and his co-workers (3), these substances de - 
serve careful consideration as promising therapeutic agents. Both strepto- 
thricin and streptomycin are characterized by selective bacteriostatic activi- 
ty against gram-positive and gram-negative bacteria. They are similar i n 
their activity in vivo. Streptomycin has much greater activity against certain 
specific gram -positive and certain gram-negative bacteria than does strepto- 
thricin. Bacillus mycoides, Serratia marcescens and the human strain of 
Mycobacterium tuberculosis, for example, are sensitive to streptomycin and 
fairly resistant to streptothricin, wh^r^as Staphylococcus aureus . Bacillus 
subtilis and Escherichia coli are sensitive alike to both substances. Both 
compounds are highly stabile. 

Both substances possess limited toxicity for animals. According to 
Robinson (4) the nature of the toxic effects produced by streptomycin and 
streptothricin appears to be identical, and these effects appear to be due to 
a histamine-like substance present in the more toxic preparations. Robinson 
believes that streptomycin possesses certain advantages over streptothricin 
from the standpoint of toxicity. 

The greater action o f streptomycin a s compared with streptothricin 
against certain gram-negative and gram -positive bacteria makes the former 
appear from the therapeutic standpoint also to be the more valuable drug. 

In experiments using animals both drugs have been shown to be active 
in vitro against a variety of bacteria, streptomycin being more effective 
against specific organisms, such as Pseudomonas aeruginosa and Proteus 
vulgaris . 

Numerous other experiments in vivo have been carried out with highly 
favorable results. It is sufficient to mention, in this connection, the results 
obtained in experiments with mice and chick embryos infected with Salmonella 
aertrvcke . Salmonella schottmulleri or Brucella abortus and treated with 
streptothricin, and those infected with Salmonella schottmulleri . pseudomonas 
aeruginosa . Shigella gallinarum or Brucella abortus and treated with strepto- 
mycin. 

The need for a chemotherapeutic agent effective against gram- negative 
bacilli is great, and streptomycin gives promise of fulfilling it. Extensive 



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toxicological and pharmacological studies of streptomycin will, however , 
have to be completed before the value of this substance in the treatment of 
bacterial disease in animals and man can be finally determined. 

(1) S.A. Waksman&H.B. Woodruff, Proc. Soc. Exper. Biol. &Med., Oct. '40. 
C2) A. Schatz, E. Bugie & S.A. Waksman, Proc. Soc. Exper. Biol. & Med., Jan. '44. 

(3) S.A. Waksman, E. Bugie & A. Schatz, Proc. Staff Meet., Mayo Clin., Nov. 15, '44. 

(4) H.J. Robinson, D.G. Smith &O.E. Graessle, Proc. Soc. Exper. Biol. & Med., Nov. '4- 

^ ^k- 



Gramicidin S : A strain of Bacillus brevis isolated from Russian soil has 
been investigated in detail, and a crystalline product of high antibacterial activi- 
ty, named Gramicidin S, has been prepared from the sediment obtained after the 
acidification of fluid cultures. This substance, which has the properties of a 
polypeptide, may be compared with gramicidin and tyrocidine, the crystalline 
polypeptides with antibacterial properties which Dubos and Eotchkiss prepared 
from cultures of another strain of B_. brevis. Like tyrocidine, but unlike the 
gramicidin of Dubos, gramicidin S acts in high dilutions against both gram- 
positive and gram-negative bacteria. It differs from tyrocidine in retaining 
its activity against gram-negative bacteria in nutrient broth. No evidence is 
given whether, like tyrocidine, it is inhibited by blood and serum. Since none 
of these substances is soluble in water, there is no question of systemic use 
in therapeutics. Both-of the substances of Dubos are, however, of low toxicity 
to tissue cells relative to their antibacterial power, and gramicidin and the 
crude product tyrothricin, which contains both gramicidin and tyrocidine, have 
been used locally in medical and veterinary practice in the United States with 
some success. From the brief report of a clinical trial of gramicidin S in a 
wide variety of local infections the results appear to be promising. (Lancet 
(Annotations) - Dec. 9, '44.) 

J^E 3|C . 3^C 3fc s|( ifc 

Physiological Effects of Salicylates: The segregation at the U.S. Naval 
Hospital, Corona, Calif., of naval personnel who have developed rheumatic 
fever has provided, the staff of that activity with an unusual opportunity t o 
study this disease and reappraise some of the presently used methods of 
therapy. A number of investigations are being conducted. Through the 
courtesy of Captain Leake and the members of the Rheumatic Fever Service, 
the Burned News Letter will be permitted from time to time to present in 
brief form the results of some of these investigations prior to the appearance 
of the papers in standard medical publications. 

Some of the studies are concerned with the action and effects of salicy- 
late as it is administered in the treatment of rheumatic fever. A renewed 



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interest in salicylate therapy was aroused slightly more than a year ago by 
a paper of Coburn which was presented in abstract form in the Burned News 
Letter of November 12, 1943. In this paper Coburn reported that when the 
plasma level of salicylate could be maintained at 35 or more mg. per c.c, 
patients in the early acute phase of rheumatic fever responded promptly with 
clinical improvement, return of the elevated sedimentation rate to normal 
levels and disappearance of clinical signs of myocarditis. The response in 
a group of controls treated with smaller doses was much less striking. 

Coburn and Kapp had shown in previous immunological studies that sali- 
cylate prevented the precipitation of an antigen by its antibbdy in vitro, that 
this effect became more marked as the concentration of salicylate in the 
solution was increased, and that the immune system became progressively 
less sensitive to the action of salicylate as the excess of antibody became 
larger (more salicylate being required to offset antibody excess). Coburn 
naturally suggested the possibility that the plasma salicylate concentrations 
achieved by the higher dosage schedules which he recommended might in- 
activate in vivo the reaction between the antibody formed by the rheumatic 
subject and the antigen produced by the hemolytic streptococcus. 

So convincing was the evidence as to the greater effectiveness of the 
higher dosage schedule advised by Coburn that it was recommended by the 
Bureau that it be adopted in the treatment of rheumatic fever in the Navy. 

Patients in the early phase of acute rheumatic fever are not available 
for study at Corona. Therefore, the original investigation of Coburn could 
not be repeated. However, the staff at Corona has had an excellent oppor- 
tunity to observe the action of high dosage of salicylates in the later phases 
of the disease and to study the physiological and pharmacological effects of 
salicylates in general. 

The effect of salicylate on the prothrombin level : Salicylic acid was 
found in 1943 by Link to be a chemical degradation product of 3,3 '-methylene - 
bis-(4-hydroxy-coumarin), the substance found in spoiled sweet clover which 
inhibits the synthesis of prothrombin. Link demonstrated that following i n - 
jection into rats of salicylic acid there occurred a temporary fall in the 
level of prothrombin which could be prevented or reversed by the adminis- 
tration of adequate amounts of vitamin K. Since then these observations 
have been confirmed by other investigators. The question naturally has been 
asked whether the maintenance of high blood levels of salicylate might result 
in an increase in the prothrombin time sufficient to produce hemorrhagic 
manifestations clinically. The situation is further complicated by the fact 
that hemorrhagic tendencies are part of the clinical and pathological picture 
of rheumatic fever. 



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The group at Corona measured in 51 subjects the effect on the pro- 
thrombin content of the blood of sodium salicylate administered over a rela- 
tively long period of time. The daily dosage of sodium salicylate and sodium 
bicarbonate administered to the subjects and the daily dosage of sodium 
bicarbonate administered to controls were as follows: 

SUB JEC TS CONTR O LS 

Sodium Salicylate Sodium Bicarbonate Sodium Bicarbonate 

1st Week 3.30 Gm. 1.2 Gm. 1.2 Gm. 

2nd " 6.75 Gm. 2.4 Gm. 2.4 Gm. 

3rd " 10.00 Gm. 4.0 Gm. 4.0 Gm. 

4th " 12.00 Gm. 4.0 Gm. 4.0 Gm. 

The changes in prothrombin levels in the men to whom sodium salicy- 
late was administered. are of considerable interest. During the first week 
(daily dosage 3.3 Gm*.) no changes occurred. In the second week, however, 
two days after the dosage had been increased to 6.75 Gm. the prothrombin 
time began to increase in a small number of cases. It was not, however, 
until the third week , when the subjects had been on a dosage of 10 Gm . sodium 
salicylate for two days, that a good percentage of the subjects had a pro- 
longation of the prothrombin time. However, with even greater increase in 
the dosage of salicylate (to 12 Gm.) the prothrombin time did not increase 
further. Prothrombin determinations in the controls showed no appreciable 
change in level during the four weeks that they received sodium bicarbonate. 
At no time -during this study were any abnormal hemorrhagic manifestations 
noted in the 51 subjects taking salicylates. 

In the course of the study of the 105 patients used in this investigation, 
it was observed that some of them were not taking their medication properly. 
This fact was easily determined by following the blood salicylate levels o f 
these patients. In another experiment in which the primary purpose was to 
determine the effect of sodium bicarbonate on the blood- salicylate level, the 
prothrombin time was followed. In this group which consisted of nine pa- 
tients, supervision of medication was extremely strict and all received their 
prescribed medication. They were given 10 Gm. of sodium salicylate daily 
for a period of three weeks with and without sodium bicarbonate. The Quick 
prothrombin time and blood salicylate level were done daily. 



As previously noted by other investigators, the prothrombin time did 
not rise until about the second or third day. In all o f these subjects the 
blood salicylate level was between 30 and 50 mg. per cent throughout the 
study. In spite of this high salicylate level, there was no significant progres- 
sive increase in the number of individuals who had a reduced prothrombin 



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level. Even at this dosage of salicylate, the increase in prothrombin time 
was not marked. At no time in any patient was any hemorrhagic manifesta- 
tion noted during this study. 

These observations confirm previous reports that salicylate has some 
effect on the prothrombin content of the blood. However, they suggest that 
this effect is minimal, and that with even high dosage of salicylate the pro- 
thrombin content of the blood is not dangerously reduced. Hemorrhage from 
therapeutic administration of salicylates is certainly unlikely. On the other 
hand, if any surgical procedure is contemplated for a patient with rheumatic 
fever who is taking large doses of salicylates, vitamin K obviously should be 
given pre- and postoperatively. 

The effect of salicylate on the hepatic parenchyma: The Van den Bergh 
reaction was indirect before, during and after the study in all of the indivi- 
duals taking part. Likewise the serum bilirubin was not increased above 
normal in any instance, nor was hepatic function altered as measured by the 
dye-retention method. Under the conditions of this experiment, therefore, 
the salicylates administered even in large doses had no detectable deleteri- 
ous effect upon the parenchyma of the liver. 

Blood salicylate levels: Among those patients in whom it could be veri- 
fied that the medication was taken as ordered, the blood- salicylate level at 
a dosage of 10 Gm. a day of sodium salicylate varied between 30 and 50 mg. 
•per cent. After medication had been discontinued, the blood salicylate level 
fell very rapidly and was nearly zero at the end of three or four days. From 
this observation it would seem that an adequate blood level of salicylate i s 
maintained in most individuals on an oral dosage of between seven and ten 
grams of sodium salicylate daily. 

The effect of salicylate on the sedimentation rate: It has been shown by 
Coburn and others that the maintenance of a high level of salicylate in a first 
acute attack of rheumatic fever is followed by a rather rapid fall in the blood 
sedimentation rate. In the studies at Corona, it was found that in spite of con- 
tinuous administration of salicylate there were a few patients who developed 
polycyclic recurrences of rheumatic fever with subsequent rise in the blood 
sedimentation rate. Most of these patients had adequate blood salicylate 
levels. In spite of this continued high dosage of salicylate, the sedimentation 
rate remained elevated in a few of these subjects throughout the study. Among 
the controls there was nearly an equal number of rises in the blood sedimenta- 
tion rate, which in most instances represented a recurrence of rheumatic 
fever. 

These studies suggest that subacute rheumatic fever does not respond 
clinically, nor does the sedimentation rate respond, to the administration of 



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salicylates in a manner comparable to that observed in a first acute attack. 
At present, there is no known explanation for this interesting difference. 

Effect of salicylate on the blood and urine : While long continued high 
dosage of salicylates was found to be followed by a very slight reduction in 
the hemoglobin content and the erythrocyte count, it is very likely that this 
change in the blood picture was due to the disease rather than the drug. The 
leukocyte count was unaffected in both the subjects and the controls. Among 
the group of 51 subjects there were only six who in one specimen had a few 
leukocytes in their urine. Similar observations were noted in eight of the 
controls. In neither subjects nor controls was albuminnoted on any occasion. 

* * 

The medical officers participating in this research at Corona were: 
Lt. Comdr. Hugh R. Butt, (MC), USNR; Capt. William H. Leake, (MC), USNR; 
Comdr. Robert F. Solley, (MC), USNR; Lt. Comdr. George C. Griffith, (MC), 
USNR; Lt. Comdr. Robert W. Huntington, (MC), USNR; Lt. Comdr. Hugh 
Montgomery, (MC) , USNR. 

Concentration of Penicillin in the Aqueous Humor Following Parenteral 
Injection: Studies using rabbits, confirmed by tests in which monkeys were 
used, have shown that penicillin is present in the aqueous humor following 
systemic injection. Concentration of the drug is always low in the primary 
aqueous fluid in spite of high blood levels. Massive doses are required to 
produce an appreciable increase in this concentration. However , the concen- 
tration is considered sufficient to be of clinical value at a dosage of 7,000 
units per kilogram of body weight in the rabbit and monkey. Repeated, fre- 
quent injections maintain a low level without increment. 

Following paracentesis of the anterior chamber, the secondary or plas- 
moid aqueous reforms within 40 minutes in sufficient quantity to produce 
normal tension in the anterior chamber. Concentration of penicillin in this 
fluid is higher than that in the primary aqueous and approaches the level in 
blood serum collected five minutes prior to the taking of the secondary 
aqueous sample. It is apparent that, as the intraocular fluid reforms after 
paracentesis, the penicillin is transmitted directly from the blood as one of 
the plasma constituents. These findings suggest that an infection accompany- 
ing a perforating injury to the eyeball might be expected to respond more 
readily to parenteral injection of the drug than one in which there is no escape 
of the intraocular fluid. 

The concentration of penicillin in the primary aqueous following a single 
intramuscular injection gradually increases, with a peak at 50 minutes. 



- 13 - 



a 

8? 
! 



a. 



.625 - 



g 

i 



o 

O .3125 



Burned News Letter, Vol. 5, No. 3 R,ESTRICTSP 

PENICILLIN LEVELS IN AQUEOUS HUMOR AND BLOOD OF 
RABBITS FOLLOWING INTRAMUSCULAR INJECTION OF 
30,000 UNITS 



=1 => 3=3' 3 

=> 3 ms. «D ID 

8 e ? S S £ 8 ¥. Sj 8 I 1 

tTTTT. TTTTM i 

UNITS PER OG- OF BLOOD 
SERUM RECOVERED 



PRIMARY AQUEOUS HUMOR 

SECONDARY AQUEOUS HUMOR 



\ 

\ 

X 



N. 



I563|- \ 

\ 

\ 

j i ! 1 1 




ii- 



0 10 30 4 0 50 60 70 80 90 100 MO 120 130 

TIME IN MINUTES FOLLOWING INJECTION 

The rate of decrease is slow, a fairly constant level being maintained for 
at least 90 minutes. The changes in concentration of drug in the secondary 
aqueous follow, in general, the changes in blood concentration. Although the 
level in the secondary aqueous is never as high as that found in early blood 
samples, resorption is slow, with the result that a curve of concentration 
plotted against time would start at a lower level but would fall more gradu- 
ally to approach or equal the blood level curve at 100 minutes after a single 
intramuscular injection of penicillin (See Graph). 



ThP Centra} of Experimental Anterior Cha mber Infections with Systemic 
ppnir.illin Therapy: Experimental studies have shown that a relatively uni- 
form infection of the anterior chamber of the rabbit eye can with regularity 
be produced for study of the action of antibacterial agents. In the experiments 
reported here, a penicillin- sensitive streptococcus was used, but e quail y 
satisfactory infections have been produced with staphylococcus. 

Penicillin by intramuscular injection was found to be effective in control- 
ling and eradicating such experimentally produced infections in the r abb it , 
provided massive injections were given every three hours over an extended 
period of time. 



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In a series of ten experimental animals with induced streptococcal 
infection of the anterior chamber, therapy with penicillin by intramuscular 
injection of approximately 5,000 units per kilogram of body weight was 
started as soon as there was clinical evidence of keratitis. Bacteriological 
studies revealed the presence of viable bacteria in the aqueous humor of the 
four animals tested prior to initiation of therapy. Because paracentesis is 
followed by the formation of a secondary aqueous fluid with a high concen- 
tration of the constituents of blood serum and because penicillin is readily 
transmitted to the aqueous fluid in this manner to produce a higher level 
than is found in the eye in which paracentesis has not been done, it was 
deemed wise to refrain from withdrawing the aqueous humor in some of the 
animals until the infection was shown to be under control by clinical exami- 
nation. Culture of each of the ten animals was negative for streptococcus 
by the eighth day. Penicillin therapy was discontinued at this time. 

Conjunctivitis, which occurred concurrently with the anterior-chamber 
infection, subsided rapidly. Hypopyon was present in seven of the ten eyes 
studied and exudate was observed in the pupillary area in eight. This exu- 
date usually appeared first as a purulent collection which progressed under 
treatment to a thin membranous exudate attached to the margin of the iris. 
In every instance, it had completely disappeared by the sixteenth day after 
therapy was started. It is of interest to note that the opacities, when they 
occurred, were at the site of needle -puncture. The corneas which showed 
minute areas of opacity had been subjected to multiple puncture. It would 
appear that perforation of the cornea in the presence of an infection in the 
anterior chamber leads to a localized infection which is not readily acces- 
sible to therapeutic agents. The regimen of therapy for one series of ani- 
mals included, in addition to systemic injection of penicillin, the withdrawal 
of aqueous humor twice daily in an effort to increase the concentration of the 
antibacterial agent at the site of infection. It was demonstrated that this 
manipulation in the presence of an infection aggravated the condition to such 
an extent as to outweigh the beneficial effect of higher levels of penicillin. 
This observation in no way invalidates a previous observation that anterior - 
chamber infection accompanied by perforating injury can be expected to re- 
spond more readily to systemic treatment than a closed infection without 
loss of aqueous fluid. (Nav. Hosp., Nav. Med. Res. Inst., Bethesda - A. E. 
Town & F. C. F. Young) 

****** 

Local Injection of Penicillin in Treatment of Pneumococcal Empyema : ' 
Local injections of penicillin were used to treat 21 cases of pneumococcal 
empyema. Twenty of the patients recovered without evidence of residual 
chronic infection, thoracic deformity, or reduction in pulmonary function. . 
In 14 of the patients a single series of one to five injections on alternate 



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RESTRICTED 



days was followed by recovery. In seven relapse occurred, but six of these 
responded to reinstitution of local treatment. The only case in which this 
mode of therapy was unsuccessful was a child of two years, who was oper- 
ated upon when the early treatment was followed by a relapse. 

The empyema fluid was promptly sterilized by penicillin, which by in 
vitro tests was shown to be active 48 hours after injection. In no case did 
relapse occur when the empyema fluid was demonstrated to have been 
sterile for as long as eight days following cessation of treatment. 

The clearing of deposits of exudation on the pleural surfaces, as deter- 
mined by X-ray, required from three to nine weeks. However, the interval 
between the first and last successful thoracenteses averaged 24 days. 

The general health of the patients during the post-therapeutic period 
of resolution was good. (Tillett et al., New York Univ. - To be published. 
CMR Bulletin #22.) 

****.** 

Experimental Transmission of Epidemic Hepatitis : Havens et al have 
recently carried out an experiment on the transmission of epidemic hepatitis, 
using 19 volunteers at two institutions. Three different samples of serum 
containing the hepatitis -producing agent were inoculated intracutaneously into 
five human subjects, and the disease was produced in three after incubation, 
periods of from 56 to 70 (average 64) days. 

Three volunteers were fed (or given intranasally) sera suspected of con- 
taining icterogenic agent. Of these, two contracted epidemic hepatitis with 
severe clinical jaundice 30 days after feeding and the third developed mild 
subicteric hepatitis after 84 days. Six volunteers were fed urine and stool 
extracts obtained from patients in various stages of epidemic hepatitis. Of 
these volunteers, two contracted hepatitis 20 and 22 days respectively follow- 
ing feeding. (Proc. Soc. Exper. Biol. & Med., Nov. '44.) 

****** 

Neurocirculatory Asthenia: Familial Incidence of the Chronic Type: 
Family histories of 57 patients with the chronic form of neurocirculatory 
asthenia (from a military hospital in the Zone of the Interior) and of 51 
normal soldiers were analyzed in an attempt to determine the incidence of 
this disorder in parents and siblings. The data indicate that there were 
definite cases of neurocirculatory asthenia in the families of 65 per cent of 
the neurocirculatory-asthenia patients and of 1.8 per cent of the controls. 
(Progress Report #11, OEMcmr-157 - P. D. White, Massachusetts General 
Hospital. CMR Bulletin #21) 

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New Type of Plastic Arm Splint Used in Evacuation : A new type of arm 
splint has been designed which should be useful under combat conditions in 
which the requirements of rapid evacuation demand prompt immobilization. 

The splint is made of a phenolic fabric board which is very light and 
strong and which is resistant to moisture and to tropical deterioration. It 
is constructed in two parts: the section for the upper arm is 9-5/16 inches 
long and that for the forearm is 18-1/2 inches long. The two sections are 
attached to each other by rivets in such 
a way as to form a right angle. Both 
sections are pierced by numerous 
slots, which provide a means of secur- 
ing the splint to the arm and of allowing 
adequate drainage. It is molded and 
shaped to provide immobilization for 
any fracture of the arm or forearm. 
The splint may be applied to either the 
right or the left arm and is designed to 
fit an arm or forearm of any size. The 
construction is such that temporary 
traction maybe applied if it be desired. 

The splints are supplied in ' 'nested" 
stacks of 12. They are expendable and 
much more easily handled than Thomas 

arm splints. They may be considered the upper -extremity counterpart of 
the plywood leg splints which have proved so valuable in this war. 




The designers are Capt. F. R. Moore (MC), USN, and Comdr. P. J. 
O'Donnell (MC) , USNR. 

As supplies of these splints are received by the Naval Medical Supply 
Depot, Brooklyn, N. Y., they are being shipped to Advance Base Depots for 
delivery to combat organizations. (Plan. Div., BuMed - J. Scripp, Jr.) 



Traction vs. Simple Immobilization in Fractures Sustained in Combat : 
Considerable controversy has arisen over the relative merits under combat 
conditions of the traction-type temporary splint and the encasement-type 
non-traction splint. 



The Thomas splint is functionally ideal in that it provides immobiliza- 
tion by traction which works toward final reduction. However, under 



Burned News Letter, Vol. 5, No. 3 RESTRICTED 



conditions of battle it has certain disadvantages. It is a cumbersome appa- 
ratus, not easily stored or transported. It is not considered expendable. 
When applied to a patient, it may be difficult to handle. Furthermore, the 
application of traction to an extremity for a considerable period of time 
frequently results in ischemia, which may cause discomfort or even gan- 
grene. There may also be painful pressure at the site of counter traction. 

Under combat conditions, speed of immobilization is essential, and the 
encasement-type splint is the more rapidly applied of the two. It does not 
offer the hazard of distal ischemia, and although it is not intended to pro- 
vide final reduction, if properly constructed and applied it offers the im- 
mobility essential for rapid evacuation. 

Reports from forward areas indicate that the encasement-type splint 
is preferred by many surgeons for immobilization of fractures during 
combat. It is their practice to postpone attempts to secure satisfactory 
reduction until the patient reaches facilities behind the front lines prepared 
for such work. (Res. Div., BuMed - J. S. Thiemeyer) 

Surgery of Heart Wounds : A series of 23 patients who had been oper- 
ated upon for stab wounds of the heart or of intracardial portions of great 
vessels has recently been reported by Elkin. This series supplements one 
of 38 cases reported by the author in November 1940. Practically all of 
the patients were operated on by members of the resident staff of the Emory 
University Division of the Grady Hospital, Atlanta, Georgia. 

The mortality rate in the earlier series was 42 per cent as compared 
with a mortality rate in the later series of 22 per cent. The author attri- 
butes this improvement in results to several factors, among which are im- 
provement in skill of the resident surgeons and earlier and more accurate 
diagnosis. While seven deaths in the first series were believed to have re- 
sulted from infection (pericarditis, pneumonia or bacteremia), there were 
no deaths from this cause in the second series. The reduction in mortality 
from infection was not due to the use of sulfonamides, since in the second 
series they were used in only one case. In no instance was a sulfonamide 
placed in the wound. The author attributes the lower incidence of fatal 
infection in the later series in the main to more meticulous technic and to 
more careful preoperative preparation. Another factor which Elkin believes 
to have been of considerable importance was the giving of intravenous fluid 
prior to operation. (See next item.) 

All of the patients in both series were operated upon because there was 
definite evidence of cardiac tamponade. This diagnosis was based upon the 



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presence of lowered arterial pressure and increased venous pressure and 
the presence of a quiet heart as noted on fluoroscopic examination . 

Venous pressure readings are not only of value in the diagnosis of tam- 
ponade but are of considerable prognostic importance. If the venous pres- 
sure is high, that in itself is evidence that the heart is carrying on its functions 
and that the cardiac output is at least sufficient to produce such pressure. 
On the other hand, a low or lowered venous pressure in the presence of tarn- . 
ponade is evidence of a failing heart and of a greatly reduced cardiac. output. 

It was noted that in all patients there was a definite lowering of the 
arterial pressure and, in 17 of the 23, blood pressure readings could not be 
recorded. In those patients who recovered there was an immediate rise in 
arterial pressure following the release of the tamponade. 

Some type of general anesthesia in which positive pressure can be used 
for inflation of the lung is preferable to local anesthesia. The difficulties 
of heart suture require that the patient be quiet, and patients with wounds of 
the heart are usually excited or may become so with the release of the tam- 
ponade. Unless they are completely anesthetized, their movements may inter- 
fere with the operation at the most inopportune time. 

The operative approach to the heart is made on the left side of the sternum, 
with the incision placed about one intercostal space belowthe external wound. 
In most Instances a transverse incision extending from about two centi- 
meters outside the nipple line and carried well across the sternum has been 
used. By this approach one or two ribs can be removed, and if necessary 
the adjacent costal cartilages cut and a portion of the sternum removed. 
The pectoralis major muscle is separated in the direction of its fibers and 
can be retracted from the surface of the three ribs. Every care should be 
taken to prevent opening the pleura, since such a complication adds materi- 
ally to the shock which the patient has already undergone. The internal 
mammary vessels must be carefully isolated and ligated. They may not 
bleed before the tamponade is released, but later hemorrhage from them 
may be fatal unless proper ligation has been performed. The pleura on the 
left is displaced from the pericardium by gauze dissection and held out of 
the wound by a wet pack. As a rule, the pericardium will be tense, and its 
pulsations weak or imperceptible. If the wound in the pericardium is seen, 
it should be enlarged or , if it is not readily found, an opening should be made be- 
tween stay-sutures. Occasionally the heart wound can be located before the 
blood and clots are removed and before the heart starts beating actively, and 
under such conditions it can be readily sutured. More often the heart wound is 
not disclosed until blood and clots are removed by suction. When the intra- 
pericardial pressure is relieved, the bleeding becomes marked and contrac- 
tions of the heart increase in force. When the wound is located, and it i s 



Burned News Letter, Vol. 5, No. 3 RESTRICTED 



most often found in the right ventricle, its closure is facilitated by placing 
the left index finger over it. In this way the bleeding will be impeded suf- , x 
ficiently to allow the passage of a suture directly under the finger. This is 
left untied for the moment and is held in the left hand for traction hemo- 
stasis while other sutures are placed and tied. Should the wound be behind 
the sternum or on the posterior surface of the heart, a stay-suture passed 
through the apex, as advocated by Beck, is of great value. By this means 
the wound may be rotated into a position favorable for suture. Wounds of 
the coronary vessels may require ligature but are not necessarily fatal . 
The pericardium should be closed loosely to allow the escape of pericardial 
fluid, but the chest wall should be sutured with careful approximation of the 
anatomic layers. - ■ 

While operation in these series was carried out as soon as the diagnosis 
of heart wound with cardiac tamponade was established, Colonel Elkin be- 
lieves that, in view of the reports from other clinics on this subject, in certain 
cases some form of conservative treatment may be tried if conditions are 
not urgent and operation does not seem to be immediately demanded. Bigger, 
Strieder and Blalock have emphasized the value of aspiration of the peri- 
cardium as a preliminary to operation. In some instances it has been found 
that aspiration alone is the only operative procedure necessary, since some 
wounds, particularly those which do not penetrate the cavities of the heart, 
have become sealed, and aspiration of the blood relieving the tamponade is suffi- 
cient to bring about a cure. Blalock advocates that, in cases of tamponade in which 
there is no bleeding into the chest or to the outside, the pericardium be as- 
pirated, but that "all facilities should be available for immediate operation 
if it becomes necessary." He further states that "if blood reaccumulates- 
rapidly following aspiration, it is agreed that exposure and suture of the 
heart wound are indicated." The direction of the knife-thrust or a bullet 
wound is notoriously misleading. The position of the cardiac wound cannot 
be determined by the wound of entrance, and the symptoms of tamponade 
are the same no matter what the source of the bleeding. It would seem then 
that only in the presence of continued improvement following aspiration with- 
out recurrence of the signs of cardiac compression should immediate suture 
not be advocated. (Ann. Surg., Dec. '44) 

The Effect of Intravenous Infusions in Acute Pericardial Tamponade: 
Evidence has recently been presented* by Cooper, Stead and Warren that 
patients with pericardial tamponade following stab or bullet wounds of the 
heart may be benefited by intravenous infusions. The physiological back- 
ground of the experiments, the results of which led to this conclusion, is set 
forth by the authors as follows: 



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Patients with stab wounds of the heart resulting in pericardial tamponade 
usually arrive at the hospital in profound shock, in coma, with cold, clammy 
extremities, arterial pressure too low to record and distended veins. 
Knowledge of the circulatory dynamics is not only of considerable theoretical 
interest but of practical importance in therapy as well. It is obvious that the 
circulation can be maintained only as long a s the venous pressure exceeds 
the elevated intrapericardial pressure. It was believed that a consideration 
of the factors leading to elevation of the venous pressure might lead to a more 
rational basis for therapy. 

The elevated venous pressure in pericardial tamponade is usually said 
to be produced by damming up of blood behind the obstruction to the venous 
inflow to the heart much as a dam causes a stream to fill up and form a lake. 
Such an analogy is applicable to the increase in venous pressure which may 
be produced in an extremity by blocking the venous outflow with a tourniquet. 
The retained blood fills and distends the veins of the part until the pressure 
within them can overcome the block. At this point the veins of the extremity 
contain more blood than before, this blood being obtained by compensatory 
vasoconstriction in other parts of the body. In this way the venous pressure 
in a part can be elevated practically to the level of the systolic arterial 
pressure. The analogy of the dammed stream is not applicable in its entirety 
in pericardial tamponade, because the circulation is a closed system in which 
the venous inflow to the heart will be decreased as a decrease in cardiac out- 
put rapidly diminishes the stream of blood entering the venous system. The 
venous pressure must be raised in some manner by the use of blood already 
in the vascular bed and not by blood being constantly fed into it from fresh 
sources. Blood in small amounts is obtained by vasoconstriction which 
forces blood from peripheral vascular beds into the larger veins. With the 
fall in arterial pressure less blood is' contained in the arterial tree, and 
thus additional blood becomes available to fill and distend the venous system. 
Therefore, the rise in venous pressure is produced by a combination of vaso- 
constriction and of redistribution of blood in the vascular bed. It must be re- 
membered that most patients with stab wounds of the heart have lost blood 
externally with the result that the vasoconstrictor mechanisms have already 
been called info play to compensate for the decrease in blood volume. Under 
these conditions the body is at a disadvantage in attempting to raise the venous 
pressure to overcome the tamponade. 

Another mechanism by which venous pressure may be elevated is by increase 
in blood volume. Increase in blood volume is important in the elevation of the 
venous pressure in chronic congestive heart failure, but it does not operate 
in acute pericardial tamponade because the onset of the latter is almost in- 
stantaneous. The capillary pressure throughout the body is elevated so that 
rapid passage of fluid into the blood stream does not occur. Since maintain- 
ing adequate circulation in pericardial tamponade is dependent upon elevation 



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of the venous pressure, it would appear that the use of intravenous fluids 
to raise the venous pressure by increasing the blood volume may be 
beneficial. 

Cooper and his co-workers produced acute pericardial tamponade in 
dogs by introducing saline solution through a tube into the pericardial sac. 
The pressure required to produce severe symptoms varied from 12 to 22 cm. 
A rapid intravenous infusion, with subsequent increase in blood volume, en- 
abled the dogs to withstand an increase of pressure of from 92 to 146 per cent. 
In two dogs severe tamponade was produced, and intravenous saline solution 
caused striking improvement, even though the pericardium was closed and 
no fluid escaped. 

The authors have administered infusions of physiologic sodium chloride 
solution to three patients with pericardial tamponade. In each case the arterial 
pressure rose and the patients became more rational. At operation the wounds 
in the heart and pericardium were found to have remained sealed in spite o f 
the rise in arterial pressure. 

In conclusion the authors call attention to the. opinion of Blalock and 
Ravitch that the tamponade can frequently be relieved by aspirating blood 
from the pericardial cavity. Blalock and Ravitch stress the fact that in 
many instances the bleeding does not recur and that operation is not neces- 
sary. The results of the authors' experiments suggest that the circulatory 
failure in acute pericardial tamponade is counteracted by the use of intra- 
venous infusions. This form of therapy may serve as a useful adjunct to the 
treatment either by aspiration or by operation. It is possible that, in certain 
selected patients, raising the venous pressure by increasing the blood volume 
will restore the circulation to a level adequate to permit the patient to survive 
without either aspiration or operation. (Ann. Surg., Dec. '44) 

^ ^ 

The Relative Efficacy of Sulfonamides in Shigella Infections : Recently 
Hardy has reported further studies of the relative efficacy of t h e various 
sulfonamides in the treatment of bacillary dysentery. The results of these 
investigations confirm earlier ones reported in the Burned News Letter of 
December 10, 1943. 

Ten sulfonamides were used in the treatment of 1,423 patients with 
proved bacillary dysentery. The response to treatment was followed by 
comparison of daily cultures, counts being made of suspicious colonies. 

The Flexner infections responded readily, the Schmitz infections a little 
more slowly, and the Sonne infections less satisfactorily (in two outbreaks 



Burned News Letter, Vol. 5, No. 3 RESTRICTED 



quite poorly) . The three varieties of Shigella studied showed the same rela- 
tive resistance to sulfonamides in vitro as they did in vivo. 

Flexner infections in adults responded as readily with two as with four 
grams of absorbable sulfonamides daily. A comparable reduction of dosage 
in Sonne infections materially reduced the efficacy of treatment. 

There were no recurrences of infection in 113 individuals who were 
treated for Flexner infection. These patients were held in isolation free of 
exposure to reinfection for two months and were tested with cultures on an 
average of 11.3 times per person; 

Hardy grades the sulfonamides as to their relative value in the treat- 
ment of shigellosis as follows: 

Superior Sulfadiazine, sulfapyrazine, sulfasuxidine 

A little less effective Sulfamerazine, sulfamethazine 

Least satisfactory of 

those widely tested Sulfathiazole, sulfaguanidine 

Not recommended Sulfathaladine (less active than sulfasuxidine, 

a chemically related compound), sulfapyridine, 
sulfanilamide . 

(Hardy, Nat. Inst. Health, U.S.P.H.S.) 

* * * * s)t * 

Comparison of Effectiveness of Quinine and Atabrine (Quinacrine) in 
falciparum Malaria : The comparative activity of quinine and atabrine in 
the treatment of European patients infected with West African strains of 
Plasmodium falciparum has recently been investigated by Findlay et al. The 
patients were divided into two groups of 40 each. Each patient in one group 
received 2.0 Gm. quinine daily for 6 days. In the other group each patient 
received 0.8 Gm. atabrine on the first day, the total dose being 2.5 Gm. in 
6 days. 

■ 

While there was wide variation in the initial parasite counts in both 
series, in the cases treated with atabrine the average count was higher. 
Despite this difference in severity, there was no significant difference in 
the response to treatment. 

The duration of fever, symptoms and parasitemia in the two groups 
are compared in the following table: 



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RESTRICTED 



AVERAGE DURATION IN HOURS 



Drug 



Fever 



Symptoms 

69.0 

63.3 



Parasitemia 



Quinine 
Atabrine 



51.0 
54.9 



40.2 
43.2 



Relapse, as indicated by a recrudescence of symptoms and fever and the 
reappearance of parasites in the blood films occurring before the patient's 
discharge from the hospital was seen in only one instance. This patient 
had been treated with quinine. Occasional return cases occurred in each 
group, but it is obviously not possible to distinguish between relapse and 
reinfection. 

The authors conclude as follows: "It is still a commonly held belief 
that quinine is the drug of choice in the treatment of malaria, atabrine being 
but an Inferior substitute. The results reported here show that such a view 
is ill-founded. It has already been demonstrated that atabrine used with 
heavy initial dosage can deal effectively with heavy Infections by Plasmodium 
falciparum. The above results indicate that it can do so at least as effectively 
as quinine. Moreover, there is no evidence that the combination of atabrine 
and quinine is superior to either of these drugs used alone (Findlay, Markson 
and Holden, 1944). 

In view of the present scarcity of quinine, there appears to be no justi- 
fication for its routine use either therapeutically or as a suppressive. It 
Should be reserved for cases exhibiting idiosyncrasy to atabrine and for 
emergencies such as cerebral malaria, in which the value of atabrine has 
yet to be demonstrated. In addition, the therapeutic administration of quinine 
to persons who have been receiving atabrine as a suppressive is apparently 
not free from the danger of inducing blackwater fever (Findlay and Stevenson, 
1944)." (Report to British War Office No. 2681-44, Dec. 14, '44.) 



The Toxicity of Sodium Arsenite (Penite) : Reports have been received 
in the Bureau that cases of arsenical dermatitis have occurred among person 
nel working with solutions of sodium arsenite (Penite) . 

A 54 per cent solution of sodium arsenite (usually diluted 1 to 40 with 
water at time of use) is an effective insecticide and larvicide for fly control 
which is used in spraying garbage dumps, latrines and bodies of the dead 
before burial. Precautions must be observed by personnel working with 
sodium arsenite to prevent inhalation of the spray mist and to avoid 



* 



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RESTR I CTE D 



contact of the skin with the solution. Individuals who have previously experi- 
enced arsenical reactions (such as dermatitis in anti- syphilitic therapy) 
should not be detailed to this work. 

Spraying is least dangerous with a decontamination sprayer directing the 
spray down wind from the operators. Care should be taken that the mist does 
not drift to areas where other personnel will be exposed. Knapsack sprayers 
and hand spray guns or any equipment that is likely to expose the operator by 
leakage should not be used. Operators of sprayers should wear filter-type 
masks. Spraying should not be done in any enclosed space where the concen- 
tration of arsenite in the air may build up to toxic levels (1.5 mg. arsenic 
per 10 cubic meters of air) . 

Insofar as practicable, bodies of the dead should be prepared for burial 
before spraying (identification tags and personal effects removed). Bodies 
treated with arsenite should be marked in a conspicuous and distinctive 
manner as a warning. (Prev. Med. Div., BuMed - J. F. Shronts). 

Too Much Rest : The healing power of rest has been acclaimed since 
Hippocrates. Every doctor can recall patients who owed their recovery to 
the rest, physical, mental and emotional, that he brought to the pain- wracked 
body. Yet like all good things one can have too much of it. Those doctors 
who, as Cole puts it, spend their lives sending patients to bed and so estab- 
lish unshakable reputations for prudence sometimes forget the shortcomings 
and dangers of rest as a remedy. American physicians, surgeons, obstetri- 
cians and psychiatrists lately combined to draw attention to the abuse of rest 
in their several branches of medicine. In traumatic surgery its limitations 
have been increasingly recognized - immobilize the fractured bone completely 
until union is sound, but actively mobilize every joint which does not need to 
be fixed, is becoming the accepted principle. A similar principle is begin- 
ning to be applied to general surgery. Riddoch, for instance, has protested 
against the long rest in bed after straightforward- hernia operation or lapa- 
rotomy, quoting the case of a house-surgeon who walked upstairs to her room 
unaided on the third day after appendicectomy, and Hill has adopted a maxi- 
mum of 10 days in bed for servicemen after, simple excision of a hernial sac. 
Powers allows his patients to get up the day after major abdominal operations, 
and in 100 consecutive cases saw no harm therefrom and a reduced period of 
convalescence. Eastman, of Baltimore, supports the views of. his colleague 
Rotstein, that no harm is done by getting a mother up on the fourth day after 
delivery - in fact, that this early rising encourages involution, stimulates the 
lochial flow, reduces the incidence of thrombophlebitis, and leaves no higher 
a proportion of retroversions than the traditional ten days . Menninger has 
little difficulty in demonstrating that the prescribing of rest in psychiatric 



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Burned News Letter, Vol. 5, No. 3 



RESTR ICTED 



and psychological disturbances is irrational, and that the restless patient 
needs not only rest but also the canalization of his energies into channels 
where they will find their legitimate and satisfying outlet. 

It is perhaps in the treatment of heart disease that there is the greatest 
tendency toward over enthusiastic prescribing of absolute rest. In the Ameri-' 
can symposium, Harrison quoted experimental work on rats to support his 
clinical impression that there is seldom any need to ke'ep patients with heart 
failure or coronary thrombosis in bed for the long periods usually recom- 
mended, and he emphasized the liability of bedridden patients to venous throm- 
bosis and the development of cardiac neurosis. The risk of embolism was 
stressed by Dock, and Levine believes that recumbency may upset the balance 
between the right and left sides of the heart and thus increase the strain on 
the failing heart, besides increasing the total blood volume. In coronary 
thrombosis we must be prepared occasionally to relax our insistence on ab- 
solute rest. Until the third week of the illness absolute rest must practically 
always be insisted on, to ensure that only the minimum of strain is put on the 
myocardial infarct until healing is well established. Even in the mildest 
cases -this is a wise rule, the only possible exception being the elderly patient. 
Subsequently, it may be well in some cases not to insist on the patient's stay- 
ing in bed for the usual six weeks. But the patient with coronary thrombosis 
has often been overworking, and this may be the first adequate rest he has 
had for years. In the treatment of acute rheumatism the decision when to 
start allowing the patient to move about is often difficult to make. It is as 
wrong to keep a child with rheumatic fever in bed too long as to allow him to 
move too early. The other group of rheumatic diseases in which rest tends 
to be abused is arthritis. In the acute stage rest is essential, but unless we 
know that we can produce a cure, or at least a real improvement in the state 
of the joint, the patient must not be allowed to vegetate in bed. The rheuma- 
tologist is familiar enough with the patient with chronic arthritis who pre- 
viously managed to contend with his crippling and lead a reasonably happy 
life, but entered on a slow but steady process of disintegration when he was 
ordered to bed. The care of the aged comes into a category by itself. Here 
it has long been recognized that absolute rest is seldom wise. Even when 
the heart is obviously failing, the old patient is often much better (and 
happier) sitting in a comfortable armchair than lying In bed. It is regret- 
table that we seldom see nowadays those large armchairs with a cushioned 
ledge fixed to the armpieces which used to be a constant feature of all medi- 
cal wards, and in which the aged patient with a failing heart spent the greater 
part of his days and nights. Attention to two points wiU sometimes alleviate 
the discomforts of rest in bed. One is the use of a bedside commode rather 
than a bedpan; the other is massage to the legs. Every patient confined to 
bed, who is not suffering from an acute infection, should have daily massage 
to the lower limbs, unless there is a lesion of the limbs themselves. Such 



Burned News Letter, Vol. 5, No. 3 



RESTRICTED 



massage reduces the risk of thrombus formation, helps to maintain the peri- 
pheral circulation, and insures that the muscles do not become atrophied 
from disuse. 

In prescribing rest, then, three cardinal principles must be recognized; 
first, we must not overlook the close integration of mind, body and psyche; 
to treat one and ignore the others is to lose our chance o f complete thera- 
peutic success. Secondly, we must remember the adage about one man's 
meat - what is rest for one man may prove the acme of unrest for another. 
Thirdly, as Minot expressed it, "rest means many things to many persons." 
In other words, rest should not be prescribed by rule -of -thumb without 
considering the type of patient and the nature of the disease. (Lancet Edi- 
torial, Dec. 16, '44) 

$ $ $ + 3(C 9fS 

Summary of Reports Received bv the CMR : A weekly "Summary of 
Reports Received" is being published by the Records Section of the Com- 
mittee on Medical Research of the Office of Scientific Research and Develop- 
ment. This Bulletin presents in abstract form selected monthly reports re- 
ceived by the CMR from the many civilian investigators carrying on research 
under contract with the OSRD. It presents also summaries of some reports 
received from studies being conducted by other agencies including the British 
and Canadian Research Councils. 

From time to time items from this Bulletin which are Considered to be 
of general interest are reproduced in the Burned News Letter. Many of the 
items contained in the Bulletin are highly technical and of interest only t o 
those doing investigative work in special fields. It would be of particular 
value to medical officers who are carrying on research which parallels in- 
vestigative work conducted by civilian or by other military groups in this 
country and abroad. It would be of particular interest to medical officers 
who are removed by military necessity from their accustomed research and 
wish to keep in touch with progress in their own and related fields. 

Such medical officers desiring to receive this Bulletin regularly should 
write to Dr. Kenneth Turner, Presbyterian Hospital, 620. West 168 Street, 
New York 32, New York. Inasmuch as the number of copies is limited, and 
hence some discretion must be exercised in acceding to requests, it is re- 
quested that applicants submit with their application a statement of the 
type of investigative work upon which they are engaged or in which they are 
interested. 



Burned News Letter, Vol. 5, No. 3 RESTRICTED 



ALNAV 231 

Subj: Human Plasma and Serum Albumin. 28 Dec 1944 

Human plasma and serum albumin appear in the Supply Catalog, Medical 
Department, U.S.N., as Stock No. Sl-1945 Serum Albumin (Human) "25 Gram 
in 100 cc. Diluent With Sterile Accessories Unit-1. Stock No. Sl-3531 Plasma 
Normal Human Dried (500 cc. Original Plasma: Complete Injection Assembly 
With Diluent) Unit-1. These materials will be issued to ships Fleet Marine 
Force and to activities outside of continental limits of U.S. In general the 
quantities requested shall be estimated as follows: 



Activities Plasma (500 cc.) Albumin (100 cc.) 



APA 


10 


(per 100 men) 


15 


(per 100 men) 


BB 


10 




15 




CA 


10 


>> 


15 




CB 


10 


>> 


15 




CL 


10 


is 


15 




CV 


10 


>> 


15 




CVE 


10 


> > 


15 




CVL 


10 




15 




CVB 


10 


>) 


15 




APH 


300 


(initial allowance) 


498 


(initial allowance) 


AH 


500 




798 




All others outside U.S. not 










mentioned above 


5 


(per 100 men) 


9 


(per 100 men) 


Fleet Marine Force 


15 




21 


> > 


Extracontinental hospitals 


1 


(per bed) 


1 


(per bed) 


Advance base components 


1 




1 


>> >> 



All ships and stations should requisition the nearest storehouse or depot for 
sufficient amounts of these items to bring their current stock to the above re- 
quired level. — SecNav. James Forrestal. 



• :){ $ + s|e jf: 

To: All Ships and Stations. . Opl3-lD-mms 

Serial 481813 

Subj: U.S. Naval Hospital, Corvallis, Oregon - SO 12 13 1 

Establishment of. 27 Dec 1944 

1. The hospital facilities at the U. S. Army Camp Adair, Corvallis, Oregon, 
acquired from the War Department on the basis of a permit to use, are hereby 
established and designated as: U. S. Naval Hospital, 

Corvallis, Oregon. 
This is an activity of the Thirteenth Naval District. 



Burned News Letter, Vol. 5, No. 3 RESTRICTED 



2. Bureaus and offices concerned take necessary action. 

--SecNav. James Forrestai. 

^ ^ sjfc ^ £ 

To: All Ships and Stations. Opl3-lC-jc 

Serial 407013 

Subj: Advance Change in U. S. Navy Regulations, 1920, 

Article 1671(2). 23 Dec 1944 

1. The following change in article 1671(2) has been approved by the Presi- 
dent, and is promulgated in advance of a printed change. It will be included 
in change No. 26. 
Article 1671(2) - Delete present paragraph (2) and substitute: 

"(2) Members of the Nurse Corps may be transferred to the retired list 
for other than physical disability under the conditions stated below and the 
annual pay of a nurse retired under these conditions shall be three per cen- 
tum of the total annual active duty pay which she was receiving at the time 
of retirement, multiplied by the number of complete years of service ren- 
dered prior to retirement, but not exceeding seventy-five per centum of 
such annual active duty pay: 

".(a) An ensign in the Nurse Corps shall be recommended. to the Secre- 
tary of the Navy for retirement upon reaching the age of fifty years or when 
she has completed twenty years of service, whichever shall occur later. 

"(b) A lieutenant (junior grade) of the Nurse Corps shall be recom- 
mended to the Secretary of the Navy for retirement upon reaching the age 
of fifty-five years or when she has completed twenty years of service, 
whichever shall occur later. 

"(c) A lieutenant or an officer of higher rank of the Nurse Corps shall 
be recommended to the Secretary of the Navy for retirement upon reaching 
-the age of fifty-eight years or when she has completed twenty years of 
service, whichever shall occur later." --OpNav. W. S. Farber. 

+ . + sf: jf: j)c + 

To: All Ships and Stations. BUMED-TWS-PIL 

L7-1/EN10(042) 

Subj: Petrolatum, Liquid, Stock No. 1-575, Removal of . 

from Contents of Boat Box, Stock No. 2-185, and 18 Dec 1944 
from All Life Rafts, Life Floats and Floater Nets. 

Refs: (a) Alnav 194-44; N.D. Bui. of 15 Oct 1944, 44-1167. 

■(b) BuMed Itr L7~1/EN10(042), Y-ec (Form ltr No. 42), of 9 Apr 1942; 
N.D. Bui. Cum. Ed. 1943, 42-2097, p. 426. 



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Burned News Letter, Vol. 5, No. 3 RE ST R ICTED 



1 . Evidence accruing subsequent to the issue of references (a) and (b) indicates 
that liquid petrolatum (mineral oil) is not effective in the prevention of ' 'im- 
mersion foot" in those who are forced to abandon ship. Therefore, reference 
(b) is hereby canceled and reference (a) is modified to the extent that the words 
"2 units stock number 1-575 and" are deleted. 

2. Steps shall be taken to remove liquid petrolatum from all boat boxes, life 
rafts, life floats and floater nets. Liquid petrolatum thus removed shall be 
taken into stock by the medical department of the activity concerned. 

— BuMed. Ross T. Mclntire. 

To: All Ships and Stations. BUMED- O-EFB 

P5-2/A9-4 

Subj: Amalgam and Precious-Metal Scrap, Handling of. 20 Dec 1944 

Refs: (a) BuSandA ltr L8-2/EN9(30-3) (SSD) , of 25 Jul 1944. 
(b) NMR&DA ltr EN9(30-3)A2-2, of 14 Oct 1944. 

1. Any gold or precious metal, in form of inlays, fillings, bridges, or other 
appliances, taken from any patient's mouth is considered to belong to the pa- 
tient and shall be given the patient. An entry to this effect shall be entered 
on said patient's Form H. 

2. All dental activities shall collect all other amalgam, precious metal and 
alloy scrap derived from the practices of dentistry in the Navy and turn it 
over to the Medical Department property officer of the activity in which it 
was collected. Such collections shall be safeguarded until disposed of in 
accordance with next succeeding paragraphs. 

3. (1) Amalgam scrap, (2) gold and platinum scrap, (3) precious metal bench 
sweepings, and (4) polishing residue shall be packaged separately. 

4. Upon receipt of above-mentioned material the Medical Department proper- 
ty officer shall forward same to the supply officer of the activity for further 
shipment and disposal (ref. (a) and (b)). 

5. This shall be done in the months of January and July of each calendar 
year except when a station or ship is decommissioned, at which time this 
material shall be turned over by the Medical Department property officer 
to the local supply officer for disposal. --BuMed. Ross T. Mclntire. 



f 



Burned News Letter, Vol. 5, No. 3 



RESTRICTED 



To: All Ships and Stations. BUMED-T 

L8-2/P3-3 

Subj: X-Ray and Electrocardiographic Films, Conserva- 
tion and Transfer of with Patients. 21 Dec 1944 

Ref: (a) Alnav 82-43; N.D. Bui. Cum. Ed. 1943, 43-2022, p. 220. 



1 . Reference (a) emphasized the urgent need for the conservation of X-ray 
films. The situation in this respect continues critical and the prospects for 
major improvement are not encouraging. 

2. To the end that films be conserved to the greatest possible degree and to 
insure continuity in the care of patients transferred between medical activi- 
ties, addresses are directed to institute immediate administrative measures 
(a) to prevent duplication of expenditure of X-ray and electrocardiographic 
films, and Cb) to transfer with the patient, clinically relevant X-ray films 
and electrocardiograms whenever possible. 

3. When X-ray films are transferred with the patient, notation shall be made 
on the NavMed H-8 (Medical History Sheet) of the Health Record or other 
medical record, and an appropriate entry filed in the X-ray file indicating 
that film has been forwarded to another activity. 

--BuMed. Ross T. Mclntire. 

To: All Ships and Stations. - BUMED -Y 

A3--3/EN10Q04-40) 

Subj: Form F, Monthly Report, Abstract of Patients - 

Discontinuance of. 21 Dec 1944 

Ref: (a) Man. of the Med. Dept., pars. 2404, 2405 and 2406. 

1. Reference directs that NavMed Form F (1940), Abstract of Patients (monthly 
report) , shall be prepared and forwarded to the Bureau monthly and when a 
ship, station or hospital is placed out of commission. 

2. Effective 1 January 1945, this monthly report, NavMed Form F (1940), Ab- 
stract of Patients, shall be discontinued. 

3. The statistical summary on the NavMed Form F (1940), Abstract of Patients, 
will be incorporated in a new Monthly Morbidity Report which will supersede 
the present Monthly Communicable Disease Report. Instructions for the 
Monthly Morbidity Report will be issued within about 30 days. 



- 31 - 



RESTRICTED 



4. These instructions do not affect the present procedures of submitting Nav- 
Med Form FA Card (Revised 1942), Individual Statistical Report of Patient. 

--BuMed. Ross T. Mclntire. 



To: All Ships and Stations. BUMED -RL-JRMcK 

P2-5/P19-H094) 

Subj: Physical Examination Prior to Release from 

Active Duty or Discharge from the Naval Service. 26 Dec 1944 

Ref: (a) BuMed ltr RL:JRMcK, P2-5/P19-K094), of 30 Oct 1944; N. D. 
Bui. of 15 Nov 1944, 44-1263. 

1 . Paragraph 3 of reference (a) directed that BuMed Form Y be prepared 
and forwarded to the Bureau when members of the naval service are examined 
for release from active duty or discharged from the service, except upon the 
recommendation of a board of medical survey. 

2. This is to advise that Forms Y will not be required in. the case of recruits 
discharged from the service upon the recommendation of aptitude boards. 
Such men should, however, be given a complete and thorough physical exami- 
nation when they are discharged, and the findings entered in their health 
records. The aptitude board reports should continue to be prepared and sub- 
mitted as heretofore. --BuMed. Ross T. Mclntre. 



32